Gonorrhoea is a common type of Sexually Transmitted Infections (STI) that can infect the genitals, rectum, and pharynx (throat) of both females and males. Gonorrhoea remains Singapore's top three main bacterial STIs, affecting 33.4 per 100,000 populations in 2016. It is caused by a bacteria known as Neisseria gonorrhoea. As the name suggests, gonorrhoea is spread through intercourse- vaginal, oral, or anal penetration. Less commonly, gonorrhoea infection can be passed on from mother to child from an infected pregnant mother to the baby.

Common symptoms of gonorrhoea in women include abnormal vaginal discharge, abnormal bleeding in between periods, and painful urination. In men, gonorrhoea may present with abnormal whitish to yellow/green urethral discharge, painful urination, or even painful testicles. In those with infections over the anus or the throat, one can experience anal itch or pain, discharge and bleeding from the anus, sore throat or neck, and painful lymph nodes.

Gonorrhoea causes abnormal whitish to yellow/green urethral discharge, painful urination, or even painful testicles.

Occasionally, one may have no symptoms when they are contracted with gonorrhoea. That does not mean they are safe from long-term health complications. In fact, in an asymptomatic person, there can be a delay in diagnosis and seeking of treatment, leading to irreversible complications from the infection, such as infertility, chronic pelvic inflammation, and pain.

Over the recent years, there have been increasing sporadic cases of treatment failure with current antibiotics. (The Current CDC health guideline suggests dual antibiotic treatment for gonorrhoea infection.) In 2018, in the UK, there were reports of repeated failures in the treatment of Neisseria gonorrhoea, requiring up to four antibiotics to eradicate the infection. Treatment failure of gonorrhoea tends to be seen in infections associated with the pharynx. This reflects the progressive emergence of multi-drug-resistant Neisseria gonorrhoea infection.

What is super gonorrhoea?

The term super gonorrhoea came about during the last few years when multiple antibiotic-resistant cases of gonorrhoea were reported in several countries, including the United Kingdom, the United States, France, Spain, Japan, and others.

The treatment of bacterial STIs such as gonorrhoea has changed over the decades due to progressive resistance to various strong antibiotics, including penicillin, sulphonamides, macrolides (such as azithromycin), fluoroquinolones (such as ciprofloxacin), and tetracycline. The current recommended treatment for gonorrhoea is a dual antibiotic regimen with ceftriaxone and azithromycin.

In super gonorrhoea, the bacteria 'outsmart' the currently recommended antibiotics, remain thriving, and tend to continue transmitting to others, hence being coined the 'superbug' of STI.

What are the factors that can lead to super gonorrhoea?

Gonorrhoea can become resistant to treatment due to:

Blind treatment, inappropriate use, unnecessary use of antibiotics

Antibiotics are often repeatedly prescribed and offered by clinicians or requested by patients without proper testing. Medications are frequently provided due to the patient’s demand and anxiety or solely based on the clinician’s discretion, leading to unnecessary and inappropriate repeated use of antibiotics. In such circumstances, the bacteria may, over time, ‘adapt’ and ‘evade’ from being ‘killed’ by the antibiotics.

Incorrect dose usage of antibiotics

Physicians and patients may not be familiar with the dosage of antibiotics. Patients may also have poor compliance with medication, not completing the full dose due to various reasons such as ‘subjectively feeling better’, concern about side effects of antibiotics, forgetfulness in taking medications, etc. These potentially can lead to sub-therapeutic treatment of gonorrhoea infection, allowing the bacteria to thrive and mutate or adaptively evade the antibiotic effect over time.

Excessive or wrongly prescribed antibiotics can lead to drug-resistant bacteria.

Progressive mutation of the bacteria Neisseria gonorrhoea

Bacteria such as Neisseria gonorrhoea tend to adapt to medicine, time, and environment. When similar antibiotics target them, the bacteria tend to adapt and mutate their internal genes to survive the antibiotics, leading to the development of resistance of bacteria when treated repeatedly with the same antibiotics.

Gonorrhoea can adapt to different anatomical environments

The presence of gonorrhoea infection in other sites, such as anal and pharyngeal (throat) sites, allows the bacteria to ‘adapt’ and ‘mutate’ with the local anatomical sites and resist the effect of antibiotics. Over time, this leads to treatment failure with the usage of conventional antibiotics when gonorrhoea is present in anatomical regions such as anal and throat.

What will happen if gonorrhoea is untreated or, in the case of super gonorrhoea – untreatable?

Effect on the individual person

Untreated gonorrhoea infection can lead to pelvic inflammatory disease and, in the long run, can lead to infertility in both males and females due to chronic inflammation and scarring from the bacteria. In females, there is a risk of ectopic pregnancy if gonorrhoea is unattended when one is trying to conceive. In pregnant women with untreated gonorrhoea, there might be complications such as miscarriage, neonatal blindness, and neurological defects. Less commonly, it can also cause infection of the bloodstream (sepsis) and joint infection.

In addition, evidence has shown the presence of untreated gonorrhoea increases the risk of a person acquiring other STIs. This is particularly imperative in incurable STIs such as HIV infection, as the risk of acquiring HIV is five times higher in a person with untreated gonorrhoea.

Effect on relationships

Gonorrhoea can be passed on easily through intercourse with sexual partners. Even if asymptomatic, there might still be transmission risks unless the bacteria is being eradicated medically.

Effect on general public health

The emergence of multi-drug resistant gonorrhoea and untreated gonorrhoea can put a high financial strain on both the individual affected and the government as a whole for public health. Prolonged infection and health complications from chronic gonorrhoea can potentially place a burden on the health system and health resources to contain and treat the infection.

Is there a vaccine or new medications against super gonorrhoea?

There is currently no immunisation vaccine against gonorrhoea infection. However, ongoing trials of a meningitis B vaccine for this condition exist. These options remain under research and have not been approved for clinical use.

Promising antibiotics, such as gepotidacin and zoliflodacin, are currently in clinical phase 3 drug trials with comparable results to ceftriaxone-azithromycin combination treatment for gonorrhoea. These medications raise the hope of future management of super gonorrhoea, though they are not clinically available yet.

The efficacy of consuming high-dose doxycycline antibiotics 72 hours after unprotected intercourse may only reduce the risk of acquiring gonorrhoea by 50-55%, suggesting it is not an effective option in preventing gonorrhoea.

What can we do to avoid and curb the progression and development of super gonorrhoea?

To avoid and stop the development of super gonorrhoea, we must:

Reduce the risk of drug resistance
Effectively reduce the transmission of gonorrhoea infection

Together, we can mitigate the risk of development of multi-drug resistant gonorrhoea with practical steps, such as:

Consider regular sexual health screening.
Only treat if the test results return positive for gonorrhoea; avoid blindly treating the condition without any tests.
Ensuring the right antibiotics with the correct doses are given and received.
Ensuring full completion of the antibiotics prescribed.
Consider multi-site gonorrhoea testing (such as throat, urine, and vaginal, anal tests) to avoid underdiagnose of the condition and further spread of the disease.
Being responsible and abstain intercourse until fully treated.
Practice safe sex at all times, and avoid chemsex or alcohol sex.
Use of barrier contraception is the right method during any form of intercourse.

References

1. Landhuis EW. Multidrug-Resistant “Super Gonorrhea” Rallies Multipronged Effort. JAMA. Published online May 03, 2024. doi:10.1001/jama.2023.15355

2. Ministry of Health Singapore. Blood-borne and Sexually transmitted Diseases Chapter 5. https://www.moh.gov.sg/docs/librariesprovider5/resources-statistics/reports/blood-borne-and-sexually-transmitted-diseases.pdf

3. https://www.cdc.gov/gonorrhea/about/index.html

4. Cannon CA, Celum CL. Doxycycline postexposure prophylaxis for prevention of sexually transmitted infections. Top Antivir Med. 2023 Dec 5;31(5):566-575.

5. Angelo Roberto Raccagni et al. Neisseria gonorrhoea Antimicrobial Resistance: The Future of Antibiotic Therapy. J Clin Med 2023 Dec 18;12(24):7767.